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Background The National Surgical Adjuvant Breast and Bowel Project B-32 trial was designed to determine whether sentinel lymph node resection can achieve the same therapeutic outcomes as axillary lymph node resection but with fewer side effects and is one of the most carefully controlled and monitored randomized trials in the field of surgical oncology. We evaluated the relationship of surgeon trial preparation, protocol compliance audit, and technical outcomes. Methods Preparation for this trial included a protocol manual, a site visit with key participants, an intraoperative session with the surgeon, and prerandomization documentation of protocol compliance. Training categories included surgeons who submitted material on five prerandomization surgeries and were trained by a core trainer (category 1) or by a site trainer (category 2). An expedited group (category 3) included surgeons with extensive experience who submitted material on one prerandomization surgery. At completion of training, surgeons could accrue patients. Two hundred twenty-four surgeons enrolled 4994 patients with breast cancer and were audited for 94 specific items in the following four categories: procedural, operative note, pathology report, and data entry. The relationship of training method; protocol compliance performance audit; and the technical outcomes of the sentinel lymph node resection rate, false-negative rate, and number of sentinel lymph nodes removed was determined. All statistical tests were two-sided. Results The overall sentinel lymph node resection success rate was 96.9% (95% confidence interval [CI] = 96.4% to 97.4%), and the overall false-negative rate was 9.5% (95% CI = 7.4% to 12.0%), with no statistical differences between training methods. Overall audit outcomes were excellent in all four categories. For all three training groups combined, a statistically significant positive association was observed between surgeons' average number of procedural errors and their false-negative rate (p = +0.188, P = .021). Conclusions All three training methods resulted in uniform and high overall sentinel lymph node resection rates. Subgroup analyses identified some variation in false-negative rates that were related to audited outcome performance measures.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2007.11.015 Byline: Michael S. Cowher (a), Kathleen M. Erb (b), William Poller (c), Thomas B. Julian (b) Keywords: Axillary biopsy; Axillary ultrasound; Breast cancer; Breast surgery Abstract: Results vary regarding the utility of perioperative axillary ultrasound (AUS) and biopsy for detecting axillary metastases. Author Affiliation: (a) Department of Surgery, Allegheny General Hospital, Pittsburgh, PA (b) Department of Human Oncology, Allegheny General Hospital, Pittsburgh, PA (c) Department of Radiology, Allegheny General Hospital, Pittsburgh, PA Article History: Received 10 July 2007; Revised 20 November 2007

Women with ductal carcinoma in situ (DCIS) are at substantially increased risk for a second breast cancer, but few strong predictors for these subsequent tumors have been identified. We used Cox regression modeling to examine the association between mammographic density at diagnosis of DCIS of 504 women from the National Surgical Adjuvant Breast and Bowel Project B-17 trial and risk of subsequent breast cancer events. In this group of patients, mostly 50 years old or older, approximately 6.6% had breasts categorized as highly dense (i.e., [greater than or equal to] 75% of the breast occupied by dense tissue). After adjusting for treatment with radiotherapy, age, and body mass index, women with highly dense breasts had 2.8 (95% confidence interval [CI] = 1.3 to 6.1) times the risk of subsequent breast cancer (DCIS or invasive), 3.2 (95% CI = 1.2 to 8.5) times the risk of invasive breast cancer, and 3.0 (95% CI = 1.2 to 7.5) times the risk of any ipsilateral breast cancer, compared with women with less than 25% of the breast occupied by dense tissue. Our results provide initial evidence that the risk of second breast cancers may be increased among DCIS patients with highly dense breasts. [J Natl Cancer Inst 2004;96:1467-72]

Whole-breast irradiation after breast-conserving surgery for patients with early-stage breast cancer decreases ipsilateral breast-tumour recurrence (IBTR), yielding comparable results to mastectomy. It is unknown whether accelerated partial breast irradiation (APBI) to only the tumour-bearing quadrant, which shortens treatment duration, is equally effective. In our trial, we investigated whether APBI provides equivalent local tumour control after lumpectomy compared with whole-breast irradiation.

With the publication of mature experiences using accelarated partial breast irradiation (APBI) and accelerated whole breast irradiation (AWBI), the use of shortened courses of radiotherapy has become increasingly popular. Dr. [...]

The use of brachytherapy--and to a lesser extent, external-beam radiotherapy--in the management of locally recurrent breast cancer following ipsilateral breast tumor recurrence (IBTR) followed by repeat breast-conservation surgery and irradiation is currently an area of intense study. The current cosmetic scoring system is inadequate to score the outcome resulting from retreatment because it does not account for the cosmetic effect of the initial treatment. We propose a modification of the scale for patients who undergo retreatment--the Allegheny General Modification of the Harvard/NSABP/RTOG scoring scale., Repeat lumpectomy and retreatment radiotherapy following ipsilateral breast tumor recurrence (IBTR) by either external-beam irradiation or brachytherapy in lieu of salvage mastectomy is an area of significant recent clinical interest. [...]

The NSABP B-35 trial compared 5 years of treatment with anastrozole versus tamoxifen for reducing subsequent occurrence of breast cancer in postmenopausal patients with ductal carcinoma in situ. This report assesses the effect of these drugs on quality of life and symptoms.

Ductal carcinoma in situ is currently managed with excision, radiotherapy, and adjuvant hormone therapy, usually tamoxifen. We postulated that an aromatase inhibitor would be safer and more effective. We therefore undertook this trial to compare anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy.

Ductal carcinoma in situ of the breast has rapidly increased in incidence over the past several decades secondary to an increased use of screening mammography. Local treatment options for women diagnosed with ductal carcinoma in situ include mastectomy or breast-conserving therapy. Although several randomized trials have confirmed a >50% reduction in the risk of local recurrence with the administration of radiation therapy (RT) compared with breast-conserving surgery alone, controversy persists regarding whether or not RT is needed in selected “low-risk” patients. Over the past two decades, two prospective single-arm studies and one randomized trial have been performed and confirm that the omission of RT after surgery is associated with higher rates of local recurrence even after selecting patients with optimal clinical and pathologic features. Importantly, these trials have failed to consistently and reproducibly identify a low-risk cohort of patients (based on clinical and pathologic features) that does not benefit from RT. As a result, adjuvant RT is still advocated in the majority of patients, even in low-risk cases. Future research is moving beyond traditional clinical and pathologic risk factors and instead focusing on approaches such as multigene assays and biomarkers with the hopes of identifying truly low-risk patients who may not require RT. However, recent studies confirm that even low-risk patients identified from multigene assays have higher rates of local recurrence with local excision alone than would be expected with the addition of RT.

The supplanting of radical mastectomy by simple mastectomy and then by lumpectomy plus radiation, the use of adjuvant therapy to alter the natural course of breast and colorectal cancer, the use of tamoxifen for the prevention of breast cancer, and the dramatic improvement in survival demonstrated with the use of the monoclonal antibody trastuzumab in women with HER2-positive breast cancer are all the direct results of research that has been carried out over the past 50 years by the National Surgical Adjuvant Breast and Bowel Project (NSABP). This National Cancer Institute–supported clinical cooperative trials group based in Pittsburgh, PA, currently has 200 member institutions and 700 satellite centers located throughout the United States, Canada, Puerto Rico, and Ireland. The NSABP's mandate is to conduct large randomized phase III trials to evaluate therapies designed to improve the treatment and prevention of breast and colorectal cancer. Over the past half century, the NSABP has entered more than 150,000 patients and participants into clinical studies that have changed the treatment of colorectal cancer and have revolutionized the treatment and prevention of breast cancer.

The incidence of ductal carcinoma in situ (DCIS) has markedly increased as a result of the use of screening mammography. Whether DCIS is a premalignant lesion or a cancer remains a cause of debate, but evidence supports the idea that DCIS evolves into invasive breast cancer based on histologic patterns, similar risk factors, and genetic similarities. Microcalcifications identified during mammography generally raise the suspicion of DCIS, and biopsy, often by core needle, confirms such a diagnosis. The extent of disease can be further delineated by breast magnetic resonance imaging. Radiation therapy in breast-conserving treatment, along with tamoxifen, decreases the overall rate of local recurrence in patients with DCIS. Studies in the treatment of DCIS exploring partial breast radiation and trastuzumab are under way. Ongoing investigations with comparative genomic hybridization suggest that there are independent, evolutionary genetic pathways within DCIS. Genome-wide microarray-based gene expression analyses are now providing new opportunities to discover genes that are specifically activated or inactivated during the course of breast cancer progression.

Occult metastases, by definition, are not detected on initial examination. They may be present on slides but missed during screening or may be present in paraffin embedded tissue blocks and undetected without additional levels. Anticytokeratin immunohistochemistry (CK IHC) enhances detection of occult metastases, particularly micrometastases (>0.2 mm but not larger than 2.0 mm) or isolated tumor cell clusters (≤0.2 mm). This study defines the rate at which pathologists miss metastases on CK IHC of sentinel lymph nodes (SLN).CK IHC sections 0.5 and 1.0 mm from the original surface of SLN tissue blocks were screened by pathologists using standard bright field light microscopes (LM) and by supervised computer assisted cell detection (CACD). All blocks were from breast cancer patients, initially classified ‘node negative’ on review of routinely stained sections from the surface of each block. Cases missed by LM screening but detected by CACD defined false negative screens.Of 236 cases screened, LM detected 34 (14.4%; 95% CI: 9.6‐20.2) cases and, in the 202 cases negative by LM, CACD detected an additional 30 (14.9%; 95% CI: 9.6‐21.2%) cases with occult metastases. Occult metastases missed by LM screening ranged from 0.01 to 0.1 mm in greatest dimension. The probability of missing an occult metastasis ≤0.02 mm; ≤0.05 mm, and ≤0.10 mm was 75%, 69.2%, and 61.2%, respectively. No occult metastases larger than 0.10 mm were missed by LM screening.Pathologists screening the CK IHC stained slides may frequently miss detecting metastases <0.10 mm. Cancer 2006. © 2006 American Cancer Society.

Few studies have attempted to critically identify patient- and tumor-related factors that limit sentinel node biopsy (SNB). These studies have been limited by sample size and surgeon variability. The present study attempts to enumerate these limitations in a unique group of patients. One hundred twenty-five SNBs performed by a single surgeon between May 1997 and June 2001 were reviewed. Overall SNB was successful in 96 per cent of patients with a 97 per cent correlation with the axillary node dissection. Sentinel node identification was not affected by age, tumor size, tumor location, prior segmental resection, or neoadjuvant therapy. No false negatives were noted in the neoadjuvant group. The use of blue dye alone significantly understaged patients when compared with isotope alone (P= 0.02). SNB is a highly accurate method to identify axillary metastases and its limitations are not affected by patient or tumor related factors. In the present study SNB detection by both isotope and blue dye has been shown to be superior to blue dye alone. This finding demonstrates that these limitations may be overcome with the standardization of the technique used.

The diagnosis and treatment of breast cancer has evolved significantly over the last 20 years. Breast‐conserving therapy is replacing the Halstedian concept of “en bloc” resection. Difficulties in detection, pre‐ and postoperative planning and follow up continue to challenge the clinician. Women at high risk present a significant clinical dilemma. MRI technology in many of these areas is providing more information about detection, tumor size, extent, and response to treatment. The careful and thoughtful inclusion of MRI in clinical trials may help continue the advancement of breast cancer care. J. Magn. Reson. Imaging 2001;13:837–841. © 2001 Wiley‐Liss, Inc.

This study constitutes the advanced stage of an ongoing project for the development of cryosurgical devices and techniques for breast cryosurgery. The current study focuses on the long-term follow-up post-cryosurgery in a sheep breast model. Results of this study indicate that the cryotreatment site in a sheep breast model cannot be identified up to 5 months post-cryosurgery by means of ultrasound, mammography, or MRI. Histology findings of this study further indicate that there is no gross or microscopic difference between lesions that have been subject to one versus three freeze/thaw cycles. Under either cryosurgical protocol, there is a main cryoinjured region that has uniform destruction of epithelium and healing scar formation and a transition zone of damaged lobules without acini, surrounded by healthy tissues. The cryoinjured region at 5 months post-cryosurgery was found to be about half the diameter of the ultrasound-imaged frozen region during the cryoprocedure. This study shows that, in terms of recovery and regeneration, surgical excision appears to have an advantage over cryosurgery, which results in a more rapid healing process. Based on observations that the cryoinjured region is no smaller than the ultrasound-imaged ice-ball and that the typical thickness of the transition zone is up to 5 mm, a conservative use of the cryosurgical device developed for the current study in an ultrasound-monitored cryoprocedure requires at least 5 mm safety margins of the frozen region radius around the target region.

Objectives To review peritoneal dialysis catheter failures and to describe a technique of repairing malpositioned catheters.Design Two prospective case reports utilizing this technique are reported.Setting A tertiary care hospital.Patients Two patients on chronic peritoneal dialysis with malfunctioning catheters.Intervention Both patients underwent reposition of their malpositioned continuous ambulatory peritoneal dialysis catheters by laparoscopic suture technique.Main Outcome Measures Outcome was measured by the successful return of adequate peritoneal dialysis.Results Both case studies show correction of malpositioned catheters with the return of successful peritoneal dialysis.Conclusion The repositioning and suture application of malpositioned Tenckhoff catheters by laparoscopic surgery is a viabletechnique that can salvage the majority of mal positioned catheters and save the patients additional hospital time and recovery.

An occult breast cancer was detected and wire localization performed using magnetic resonance imaging.

The second phase of a pilot study dealing with the mechanical response of frozen biological tissues to external compressive load is presented. This stage deals with histological observations of the damage accompanying mechanically induced permanent deformation in frozen rabbit liver. No significant gross histological damage was observed in the liver samples due to either processing the tissue in the frozen state, due to slow cooling of the liver tissues down to −20°C, or due to rapid cooling of the samples down to −196°C. No histological changes were observed in tissue samples that were loaded within the elastic regime, that is, below the yield strength of the material. Therefore, it is concluded that histological changes due to mechanical stresses are associated with plastic (permanent) deformations. Histological observations indicate that linear cracks which appear to have no preferred orientation develop due to mechanical stress beyond the yield strength of the frozen tissue. These cracks accumulate until final failure of the frozen tissue, when the tissue sample collapses to rubble. Based on histological observations and concepts from solid mechanics, an interaction between crack formation and irregularities in the frozen medium is suggested. Significant sources for such irregularities, in an homogeneous tissue such as the liver, are blood vessels and bile ducts. These irregularities may either initiate crack formation or, on the other hand, may also arrest propagating cracks.

The tour de force of this paper lies in the review of clinical presentation of occluded Greenfield filters in a group of patients contraindicated for postopera tive anticoagulation. Nine of 59 patients (15.3%) had occluded filters. Eight of these 9 patients (88.8%) had primary brain tumors. This study, for the first time, to the authors' knowledge, reports a high incidence of caval thrombosis in brain tumor patients (8/31:25.8%) and of an association between caval throm bosis and recurrent deep vein thrombosis. Deep vein thrombosis (DVT) was seen in 88.8% of patients with caval thrombosis in this service. It is the authors' contention that recurrent DVT, at least in brain tumor patients, should alert the physician to evaluate caval patency. Caval thrombosis was noticed even sixty weeks after the placement of Greenfield filter. The authors conclude, therefore, that brain tumor patients had a high incidence of occluded filters; lower extrem ity morbidity provided a clue to such an event, and such a scenario should raise concerns regarding caval patency, even in long-term follow-up.

An experimental study involving circular stapled anastomoses across linear stapled closures is presented. Although the staples were deformed, cut in two, and sometimes uninjured, no complications were found. These data support the use of this technique, which is currently employed in clinic practice.

Summary A 31-year-old woman presented with constant epigastric pain. Obstruction of the pancreatic duct was observed by ultrasonography and CT scan and was further defined by ERCP. Surgical exploration of the pancreas revealed a tumor in the pancreatic head. Histologic and immunocytochemical examination revealed a benign granular cell tumor, a neoplasm not previously described as causing obstruction in the pancreas.

The microcirculatory evolution of healing wounds has not been well documented. The authors tested the generally accepted hypothesis that an end-to-end, stapled anastomosis (EEA) causes less microcirculatory compromises to the wound edge than an end-on, single-layer, hand-sewn anastomosis (HSA) does. The quanti tative measurement of the microcir culation associated with hand-sewn and stapled colonic anastomoses was carried out in two groups of dogs, each containing 28 animals. The mi crocirculatory evolution with use of either technique was similar, and the data in this study failed to support the common belief that the "B" shape of the staples results in mini mal trauma to the microcirculation and thus allows capillary growth through the tissue enclosed by the staple. In contrast to other studies, however, the authors noticed cross- circulation as early as the third post operative day in either technique. Moreover, by this angiographic method, they noted a gradual in crease in the extent of cross-circula tion from days 3 to 13 in both types of anastomoses. To their knowledge this study represents the first report of a comparison of trauma caused to the microcirculation by mechanical su tures and single-layer, hand-sewn technique.

An experimental study of the mechanical response of frozen soft biological tissues to applied compressive stresses is presented. This study is related to the mechanical stresses that develop due to the contraction of frozen tissues in cryopreservation as well as in cryosurgical procedures. The main concept in this study is that the stresses associated with the constrained contraction of the frozen tissue, i.e., due to temperature variations within the frozen tissue, can be simulated by an external mechanical load which is applied to the frozen tissue while the tissue is maintained at a uniform temperature. A new apparatus for measuring compressive stresses and strains of frozen biological tissues in cryogenic temperature range is presented. A new technique for processing the fresh biological tissue into a cylindrical frozen sample for mechanical testing is introduced. Results of compression tests on rabbit liver, kidney, and brain are presented and are compared with available data from the literature on sea ice and single ice crystals. An unusual response of frozen biological tissues to compressive stress was observed: after the initial, roughly linear elastic portion there was a series of sudden stress drops at constant strain, each followed by a linear increase of stress with strain to the next drop. This phenomenon, which is attributed to the accumulation of microcracks, broadly resembles plastic deformation, and thus provides some support for simple mechanical models invoked in theoretical studies.

Despite clinical assessment and mammography, as many as 10% of women treated for breast cancer have unrecognized disease in the other breast. Preliminary studies suggest that magnetic resonance imaging (MRI) is able to detect many otherwise occult contralateral tumors. This study attempted to show whether MRI does in fact aid the detection of contralateral breast cancer. A total of 969 women aged 18 and older who recently were found to have unilateral breast cancer participated in the study. In all cases the other breast was normal clinically and on mammography. MRI-detected cancers were confirmed by biopsy within a year of entry into the study. Contrast-enhanced MRI was performed using a dedicated breast-surface coil. Participating radiologists were experienced in interpreting breast MRI scans.

• Inflammatory aneurysms of the abdominal aorta (IAAAs) have distinctive clinical and physical characteristics that separate them from typical atherosclerotic aneurysms. They were identified in 19 (7.2%) of 265 patients undergoing abdominal aortic aneurysm repair. Symptoms were present in 12 (63%) of 19, with one patient presenting with rupture, and multiple symptoms were present in six (32%). Intraoperatively, all aneurysms exhibited dense periaortic inflammation. Adjacent structures most frequently involved were the duodenum in 15 (79%) of 19 patients, the left renal vein in six (32%) of 19, and the ureter in five (26%) of 19. Seventeen (94%) of the 18 patients who underwent elective aneurysm resection survived. The involvement of retroperitoneal structures varied in number and severity, demonstrating that a wide spectrum of inflammation is present in IAAAs, making diagnosis and definition difficult.(Arch Surg 1989;124:673-675)

Ductal carcinoma in situ (DCIS) of the breast historically has been a disease detected by physical examination, diagnosed by open surgical biopsy, and treated by mastectomy and axillary dissection. It is now increasingly detected by screening mammography, diagnosed by needle core biopsy, and treated by lumpectomy, with axillary dissection having been abandoned and sentinel node biopsy being used in axillary staging. However, outcomes related to sentinel node biopsy in DCIS have not been validated in well-controlled clinical trials. Current guideline recommendations are to use sentinel node biopsy when needle core biopsy is highly suspicious for invasive cancer or where there is a high-risk DCIS when lumpectomy identifies invasive breast cancer with the DCIS, or when mastectomy is performed for extensive DCIS. Routine use of sentinel node biopsy for DCIS is not supported.